Religious Factors in Bipolar Disorder

a man praying in the water

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Having an increased focus on religion or religious activities is a possible symptom of mania and hypomania in bipolar disorder. This heightened focus isn't necessarily unique to bipolar disorder, however, as it is also associated with schizophrenia, schizophreniform disorder, schizoaffective disorder, and other psychotic disorders.

This increased religiosity may take many forms—some more subtle than others and not all are indicative of psychosis. Here are some examples (using hypothetical patients):

  • Janie was raised in a Protestant home but stopped going to church in her teens. After the onset of bipolar symptoms, though, she began going to more than one service a week, volunteering, joining study groups, and seeking personal religious counseling from the minister.
  • Ed had never been to any religious service or events in his life, but as he developed symptoms of mental illness and was later diagnosed with schizophrenia, he began talking to friends about God more and more, reading the Bible, eventually falling to his knees and praying aloud regardless of where he was.
  • When Terri, a devout Jew all her life, developed a schizoaffective disorder, she became convinced that God felt she was unworthy and attempted suicide.
  • Jerry, who has bipolar disorder, began to focus more on his religious beliefs when his symptoms began, finding that they helped sustain him in difficult times.

Terri's doctor may provide an immediate diagnosis of having religious delusions. But in the cases of Janie and Ed, a psychiatrist might feel such a diagnosis would be premature. And in Jerry's case, at this point, his beliefs appear to be supportive rather than problematic.

As psychiatrist Harold G. Koenig, professor of psychiatry and behavioral sciences at Duke University, wrote in his 2007 review of the literature on the subject, "While about a third of psychoses have religious content, not all religious experiences are psychotic."

Koenig found that some spiritual approaches may be of benefit to the patient—as in Jerry's case. When religious delusions aren't immediately obvious, the treating clinician needs to examine the patient's religious beliefs and behaviors carefully, Koenig concluded.

What Are Religious Delusions?

Delusions are defined as "false beliefs firmly held," and different types include paranoid or persecutory delusions, delusions of reference, delusions of grandeur, delusional jealousy and others. Two of these, in particular, may express themselves in a religious context. Here are a few examples:

Religious paranoid delusions: "Demons are watching me, following me, waiting to punish me if I do anything they don't like," or "If I put on my shoes, God will set them on fire to punish me, so I have to go barefoot all the time." Auditory hallucinations, such as, "The voices keep telling me there are devils in my room," are often combined with religious paranoia.

Religious delusions of grandeur: "God has exalted me above you, normal people. He tells me I don't need help, don't need medicine. I'm going to heaven and all of you are going to go to hell," or "I am Christ reborn."

Cultural Effects on Religious Delusions

A 2015 meta-analysis of 55 studies examined the relationship between religious delusions (RD) and religious hallucinations (RH) in countries around the world.

In the United States, a 2001 study found that the level of religious involvement predicted the severity of religious delusions, and that Protestants were more likely to experience RD than Roman Catholics. In 2002, a study in England reported a higher association of religious belief and religious delusion in subjects with schizophrenia.

Additionally, a 2010 study on Muslim patients with schizophrenia in Pakistan said that "more religious patients are both more likely to experience RD and to hear voices of ‘paranormal agents.’ 

Contrary to these findings, however, the meta-analysis also pointed out that a 2008 study conducted on schizophrenic patients in Lithuania "concluded from their multivariate analysis that religiosity does not directly influence the religious content of delusions," and that more research was still needed.

Koenig reported that "Patients with severe and persistent mental illness often come for treatment with religious delusions. In the United States, approximately 25%–39% of patients with schizophrenia and 15%–22% of those with mania / bipolar have religious delusions."

Impact of Religion and Religious Delusions in Psychotic Disorders

Many patients with psychotic disorders consider spiritual faith to be an important coping mechanism. For those who are not delusional, religious beliefs and activities as coping mechanisms have been found in some studies to be associated with better outcomes for the illness as a whole.

Conversely, having religious delusions has been found to be associated with a more serious course of illness and poorer outcomes. Research has shown that patients with religious delusions had more severe psychotic symptoms, a longer history of illness, and poorer functioning prior to the onset of a psychotic episode.

You can see why, then, it's essential for clinicians to be aware of these differences.

Doctors ought to include a patient's beliefs in evaluating the patient as a whole and use care in distinguishing between strong religious beliefs and delusions.

Religion, Delusion, and Psychosis

Despite the conflicting research on whether the culture of a country has an effect on the incidence of religious delusions, it is certainly an area of interest for further study.

If there's one thing that researchers do agree on, it's that those who treat people with psychoses need to be sensitive to a patient's non-delusional religious beliefs, both in distinguishing them from delusions and in evaluating how helpful they are potentially to the patient.

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